The septal bulge - an early echocardiographic sign in hypertensive heart disease

Patients in the early stage of hypertensive heart disease tend to have normal echocardiographic findings. The aim of this study was to investigate whether pathology-specific echocardiographic morphologic and functional parameters can help to detect subclinical hypertensive heart disease. One hundred ten consecutive patients without a history and medication for arterial hypertension (AH) or other cardiac diseases were enrolled. Standard echocardiography and two-dimensional speckle tracking -imaging analysis were performed. Resting blood pressure (BP) measurement, cycle ergometer test (CET), and 24-hour ambulatory BP monitoring (ABPM) were conducted. Patients were referred to "septal bulge (SB)" group (basal-septal wall thickness >= 2 mm thicker than mid-septal wall thickness) or "no-SB" group. Echocardiographic SB was found in 48 (43.6%) of 110 patients. In this SB group, 38 (79.2%) patients showed AH either by CET or ABPM. In contrast, in the no-SB group (n = 62), 59 (95.2%) patients had no positive test for AH by CET or ABPM. When AH was solely defined by resting BP, SB was a reasonable predictive sign for AH (sensitivity 73%, specificity 76%). However, when AH was confirmed by CET or ABPM the echocardiographic SB strongly predicted clinical AH (sensitivity 93%, specificity 86%). In addition, regional myocardial deformation of the basal-septum in SB group was significantly lower than in no-SB group (14 +/- 4% vs. 17 +/- 4%; P < .001). In conclusion, SB is a morphologic echocardiographic sign for early hypertensive heart disease. Sophisticated BP evaluation including resting BP, ABPM, and CET should be performed in all patients with an accidental finding of a SB in echocardiography

Longitudinal systolic and diastolic strain rate and strain.

<p>Non-survivors vs. survivors <i>P</i><0.05 indicated significantly different. LS_sys: longitudinal peak systolic strain; LSR_sys: longitudinal peak systolic strain rate; LSR_dias: longitudinal peak early diastolic strain rate; E/LSR_dias: early diastolic peak filling velocity to global LSR_dias ratio; LSsys_api/bas: septal apical to basal longitudinal systolic strain ratio.</p><p>Longitudinal systolic and diastolic strain rate and strain.</p

The receiver operating characteristic (ROC) analysis of global early diastolic strain rate (LSR_dias) for predicting mortality (left) and cumulative survival stratified by the optimal cut-off value for global LSR_dias (right).

<p>Global LSR_dias serves as the best marker for predicting mortality in cardiac amyloidosis patients with preserved ejection fraction (area under of ROC curve: 0.72 (0.56–0.89), <i>P</i> = 0.019). CA Patients with global LSR_dias <0.85 S⁻¹ suggests about 4-fold increase of all-cause mortality than those with preserved global LSR_dias value.</p

Incremental model performance for predicting prognosis assessed by starting with the clinical variables (Model I: age, NYHA class, and number of non-cardiac organs involved), followed by the conventional echocardiographic parameters (Model II: adding MAPSE and E/E′ to model I), and finally by adding advanced global LSR_dias (Model III).

<p>MAPSE: mitral annular plane systolic excursion; E/E′: early diastolic peak filling velocity to tissue Doppler early diastolic septal mitral annular velocity ratio. LSR_dias: longitudinal peak early diastolic strain rate.</p

Examples for the measurement of longitudinal peak early diastolic strain rate (LSR_dias) from two-dimensional speckle tracking imaging.

<p>On the upper panel, solid colored lines indicate corresponding segmental strain rate curves and white dashed line indicates global strain rate curve. The measurements of longitudinal systolic strain rate (LSR_sys) and LSR_dias in the basal-septal segment are shown (yellow line) on the lower panel. AVC: aortic valve closure; MVO: mitral valve opening.</p

Echocardiographic characteristics.

<p>Non-survivors vs. survivors <i>P</i><0.05 indicated significantly different. LV: left ventricle; RV: right ventricle; LA: left atrium; RA: right atrium; IVS: interventricular septum; LVMI: LV mass indexed to body surface area; EF: ejection fraction; MAPSE: average of mitral annular plane systolic excursion measured at the septal and lateral sites; TAPSE: tricuspid annular plane systolic excursion; E: early diastolic peak filling velocity; A: late diastolic peak filling velocity; E′: tissue Doppler early diastolic septal mitral annular velocity. DT: deceleration time of early diastolic peak velocity; IVRT: isovolumic relaxation time; SPAP: systolic pulmonary artery pressure.</p><p>Echocardiographic characteristics.</p

Prediction for Mortality by univariable Cox proportional hazard regression analysis.

<p>CI: confidence interval. For abbreviations, see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0115910#pone-0115910-t002" target="_blank">table 2</a> and <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0115910#pone-0115910-t003" target="_blank">3</a>.</p><p>Prediction for Mortality by univariable Cox proportional hazard regression analysis.</p

Multivariable Cox proportional hazard regression analysis.

<p>Adjusted for age and gender with a backward stepwise method (likelihood ratio). For abbreviations, see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0115910#pone-0115910-t002" target="_blank">table 2</a> and <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0115910#pone-0115910-t003" target="_blank">3</a>.</p><p>Multivariable Cox proportional hazard regression analysis.</p

Scatterplot and error bar (mean±2SD) of LSsys_api/(LSsys_bas+LSsys_mid+LSsys_api) in the septum.

<div><p>Pathological base-to-apex gradient was defined as LSsys_api/(LSsys_bas+LSsys_mid+LSsys_api) ≥0.45. Pathological gradient of the septum was present in 32 out of 44 patients (73%) with AL amyloidosis and LV hypertrophy [9 (50%) compensated, 23 (88%) decompensated, P<0.05].</p> <p>*: P<0.05 vs. Controls; †: P<0.05 vs. Compensated group. LSsys_api: apical longitudinal systolic strain; LSsys_mid: mid longitudinal systolic strain; LSsys_bas: basal longitudinal systolic strain.</p></div